Multiple Faces of Cerebral Small Vessel Diseases

Effect of Stellate Ganglion Block on Dysphagia and Cognitive Impairment in Cerebral Small Vessel Disease: A Randomized Controlled Study

BACKGROUNDS

Cerebral small vessel disease (CSVD) can potentially and frequently lead to dysphagia and cognitive impairment. Stellate ganglion block (SGB) can alleviate the symptoms by regulating neural pathways and improving cerebral blood circulation.

OBJECTIVES

This study aimed to explore the clinical effect of SGB on airway protection, dysphagia, cognitive impairment, and activities of daily living (ADL) in CSVD patients.

METHOD

This was a randomized controlled study conducted from February 2021 to May 2023, including 84 CSVD patients with dysphagia and cognitive impairment. The participants were randomly divided into the SGB group (n = 42) and the untreated group (n = 42). All received standard-of-care rehabilitation for 20 days. The SGB group received SGB once a day additionally. Assessments were conducted on Day 1 and Day 20, respectively. The Penetration-Aspiration Scale (PAS) was primary outcome. Modified Barium Swallow Impairment (MBSImp), Mini-Mental State Examination (MMSE), Modified Barthel Index (MBI) and adverse events were secondary outcomes. This study was registered at ClinicalTrials.gov, Identifier: NCT06176404.

RESULTS

There were two dropout cases in the untreated group. Time effect with statistical significance was observed in all assessments (p < .05). Group effect with statistical significance was observed in the PAS (z = -17.283, p < .001), MBSImp-Oral (z = -3.382, p = .001), MBSImp-Pharyngeal (z = -2.639, p = .008), MMSE (F = 7.450, p = .008), and MBI (F = 6.408, p = .013). During the treatment, there were no severe adverse events.

CONCLUSION

SGB can significantly and safely improve airway protection, dysphagia, cognitive function, and ADL in CSVD patients with dysphagia and cognitive impairment who received standard-of-care rehabilitation.

Remote Ischemic Conditioning in Stroke Recovery

Remote ischemic conditioning (RIC) is a therapeutic strategy to protect a vital organ like the brain from ischemic injury through brief and repeat cycles of ischemia and reperfusion in remote body parts such as arm or leg. RIC has been applied in different aspects of the stroke field and has shown promise. This narrative review will provide an overview of how to implement RIC in stroke patients, summarize the clinical evidence of RIC on stroke recovery, and discuss unresolved questions and future study directions.

Etiology of Primary Cerebellar Intracerebral Hemorrhage Based on Topographic Localization

BACKGROUND

Cerebellar intracerebral hemorrhage (cICH) is often attributed to hypertension or cerebral amyloid angiopathy (CAA). However, deciphering the exact etiology can be challenging. A recent study reported a topographical etiologic relationship with superficial cICH secondary to CAA. We aimed to reexamine this relationship between topography and etiology in a separate cohort of patients and using the most recent Boston criteria version 2.0.

METHODS

We performed a retrospective analysis of consecutive patients with primary cICH admitted to a tertiary academic center between 2000 and 2022. cICH location on brain computed tomography/magnetic resonance imaging scan(s) was divided into strictly superficial (cortex, surrounding white matter, vermis) versus deep (cerebellar nuclei, deep white matter, peduncular region) or mixed (both regions). Magnetic resonance imaging was rated for markers of cerebral small vessel disease. We assigned possible/probable versus absent CAA using Boston criteria 2.0.

RESULTS

We included 197 patients; 106 (53.8%) were females, median age was 74 (63-82) years. Fifty-six (28%) patients had superficial cICH and 141 (72%) deep/mixed cICH. Magnetic resonance imaging was available for 112 (57%) patients (30 [26.8%] with superficial and 82 [73.2%] with deep/mixed cICH). Patients with superficial cICH were more likely to have possible/probable CAA (48.3% versus 8.6%; odds ratio [OR], 11.43 [95% CI, 3.26-40.05]; P<0.001), strictly lobar cerebral microbleeds (51.7% versus 6.2%; OR, 14.18 [95% CI, 3.98-50.50]; P<0.001), and cortical superficial siderosis (13.8% versus 1.2%; OR, 7.70 [95% CI, 0.73-80.49]; P=0.08). Patients with deep/mixed cICH were more likely to have deep/mixed cerebral microbleeds (59.2% versus 3.4%; OR, 41.39 [95% CI, 5.01-341.68]; P=0.001), lacunes (54.9% versus 17.2%; OR, 6.14 [95% CI, 1.89-19.91]; P=0.002), severe basal ganglia enlarged perivascular spaces (36.6% versus 7.1%; OR, 7.63 [95% CI, 1.58-36.73]; P=0.01), hypertension (84.4% versus 62.5%; OR, 3.43 [95% CI, 1.61 to -7.30]; P=0.001), and higher admission systolic blood pressure (172 [146-200] versus 146 [124-158] mm Hg, P<0.001).

CONCLUSIONS

Our results suggest that superficial cICH is strongly associated with CAA whereas deep/mixed cICH is strongly associated with hypertensive arteriopathy.

Relationship between cognitive dysfunction and the promoter methylation of PER1 and CRY1 in patients with cerebral small vessel disease

Background and purpose

The prevalence of cerebral small vessel disease (CSVD) is increasing due to the accelerating global aging process, resulting in a substantial burden on all countries, as cognitive dysfunction associated with CSVD is also on the rise. Clock genes have a significant impact on cognitive decline and dementia. Furthermore, the pattern of DNA methylation in clock genes is strongly associated with cognitive impairment. Thus, the aim of this study was to explore the connection between DNA promoter methylation of PER1 and CRY1 and cognitive dysfunction in patients with CSVD.

Methods

We recruited patients with CSVD admitted to the Geriatrics Department of the Lianyungang Second People's Hospital between March 2021 and June 2022. Based on their Mini-Mental State Examination score, patients were categorized into two groups: 65 cases with cognitive dysfunction and 36 cases with normal cognitive function. Clinical data, 24-h ambulatory blood pressure monitoring parameters, and CSVD total load scores were collected. Moreover, we employed methylation-specific PCR to analyze the peripheral blood promoter methylation levels of clock genes PER1 and CRY1 in all CSVD patients who were enrolled. Finally, we used binary logistic regression models to assess the association between the promoter methylation of clock genes (PER1 and CRY1) and cognitive dysfunction in patients with CSVD.

Results

(1) A total of 101 individuals with CSVD were included in this study. There were no statistical differences between the two groups in baseline clinical data except MMSE and AD8 scores. (2) After B/H correction, the promoter methylation rate of PER1 was higher in the cognitive dysfunction group than that in the normal group, and the difference was statistically significant (adjusted p < 0.001). (3) There was no significant correlation between the promoter methylation rates of PER1 and CRY1 in peripheral blood and circadian rhythm of blood pressure (p > 0.05). (4) Binary logistic regression models showed that the influence of promoter methylation of PER1 and CRY1 on cognitive dysfunction were statistically significant in Model 1 (p < 0.001; p = 0.025), and it still existed after adjusting for confounding factors in Model 2. Patients with the promoter methylation of PER1 gene (OR = 16.565, 95%CI, 4.057-67.628; p < 0.001) and the promoter methylation of CRY1 gene (OR = 6.017, 95%CI, 1.290-28.069; p = 0.022) were at greater risk of cognitive dysfunction compared with those with unmethylated promoters of corresponding genes in Model 2.

Conclusion

The promoter methylation rate of PER1 gene was higher in the cognitive dysfunction group among CSVD patients. And the hypermethylation of the promoters of clock genes PER1 and CRY1 may be involved in affecting cognitive dysfunction in patients with CSVD.

Role of Vitamin D Deficiency in the Pathogenesis of Cardiovascular and Cerebrovascular Diseases

Deficiency in vitamin D (VitD), a lipid-soluble vitamin and steroid hormone, affects approximately 24% to 40% of the population of the Western world. In addition to its well-documented effects on the musculoskeletal system, VitD also contributes importantly to the promotion and preservation of cardiovascular health via modulating the immune and inflammatory functions and regulating cell proliferation and migration, endothelial function, renin expression, and extracellular matrix homeostasis. This brief overview focuses on the cardiovascular and cerebrovascular effects of VitD and the cellular, molecular, and functional changes that occur in the circulatory system in VitD deficiency (VDD). It explores the links among VDD and adverse vascular remodeling, endothelial dysfunction, vascular inflammation, and increased risk for cardiovascular and cerebrovascular diseases. Improved understanding of the complex role of VDD in the pathogenesis of atherosclerotic cardiovascular diseases, stroke, and vascular cognitive impairment is crucial for all cardiologists, dietitians, and geriatricians, as VDD presents an easy target for intervention.

Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (pre-dementia) stage

The paper presents experts' opinion on the clinical manifestations and diagnosis of chronic cerebrovascular disease (CVD) (chronic cerebral ischemia (CCI) and dyscirculatory encephalopathy (DEP)) at the pre-dementia stage. It is noted that DEP/CCI is a common diagnosis in Russian neurological practice, the criteria for which have not been updated for a long time. DEP/CCI most often develops in the presence of cerebral small artery (CSA) disease (cerebral microangiopathy (CMA)), the severity of which can be quantified by magnetic resonance imaging. The main clinical manifestation of DEP/CCI is cognitive impairment that may be subjective or moderate at the pre-dementia stage. Emotional disorders (apathy, depression, anxiety) and instability are considered as possible manifestations of CSA disease. It is noted that headache and vestibular vertigo are not caused by chronic CVD; while in patients with CMA, they are usually associated with other diseases (primary headache, peripheral vestibular vertigo, and vestibular migraine). The diagnosis of DEP/CCI should be based on the presence of cognitive impairment, reliable neuroimaging signs of CVD, and the exclusion of another cause of cognitive impairment.